Research Article J Anest & Inten Care Med Volume 5 Issue 1- January 2018 Copyright © All rights are reserved by Siavash Beiranvand DOI: 10.19080/JAICM.2018.05.555653 The Incidence of Vasovagal Response in Spinal Anesthesia during Surgery

Sepideh Vahabi1, Siavash Beiranvand1* and Badiozaman Radpay2 1Faculty of Medicine, Department of Anesthesiology, Lorestan University of Medical Sciences, Khorramabad, Iran 2Faculty of Medicine, Department of Anesthesiology, Shaheed Beheshti University of Medical Sciences, Tehran, Iran Submission: December 23, 2017; Published: January 11, 2018 *Corresponding author: Siavash Beiranvand, Assistant Professor Anesthesia, Lorestan University of Medical Sciences, Khorramabad, Iran, Email:

Abstract Objective:

Vasovagal symptoms for sinus bradycardia are associated with hypotension in spinal anesthesia or immediately after it without the presence of high levels of anesthetic. Imbalance between sympathetic and parasympathetic control of the heart rate can be the cause of this syndrome.Methods: Aim of this study, the incidence of vasovagal reflex and its influencing factors in patients undergoing spinal anesthesia were studied.

In this descriptive epidemiological study, 284 patients who were candidates for surgery, under spinal anesthesia which was performed after obtaining written consent. Our study tool was a questionnaire that includes variables such as age, sex, and body mass index, the type of surgery, the anesthesia, fasting time, the positions immediately after spinal anesthesia, ASA class and whether elective or emergency, respectively. Heart and blood pressure were monitored in spinal anesthesia patients. Symptoms of bradycardia and hypotension with loss of consciousness,Results: without anesthesia level above the T10 positively were recorded and the data collected were analyzed with SPSS software.

The incidence of vasovagal response in our study population was 4%. In our study between age, sex, BMI, ASA class, anesthesia level S1-S5 and having a history of vasovagal reflex and reflexes shows a significant differences (P<0.05). On the contrary, the type of surgery, duration of fasting before surgery, the patient and the type of positions being elective or emergency surgery, showed that there was no significant relationshipConclusion: (P<0.05).

The incidence of vasovagal response in younger people, male as well as people who have a higher BMI is higher. The rate of vasovagal response in patients who have an underlying disease is more. To prevent vasovagal response, measures such as proper hydration Keywords:before anesthesia, patient monitoring and knowing the history of previous attacks is frequently recommended.

Vasovagal reflex; Spinal anesthesia; Surgery; Bradycardia; Hypotension; Spinal Anesthesia Introduction medical interventions, such as blood, injections and stitches syncope, a condition that is caused as a result of vagus nerve Vasovagal reflex, which is also called neurocardiogenic nursing care rectal temperature, the pressure on the carotid sinus, stimulation regardless of the mechanism that triggers its sleep deprivation, exposure to extreme heat, such as registered onset is similar in different cases [1,2]. Brain stem cells can be directly or indirectly activated by a stimulus that increases the severe cough, and swallowing [4-6]. Vasovagal response is usually parasympathetic tone of the nervous system (vagus nerve), repeated when the person is exposed to certain stimulation. Before symptoms such as light headedness, Nausea, feeling hot or too losing consciousness there is common experiences and early that causes heart rate (negative Chrono-tropic effect) and causing hemodynamic responses in the following; whole heart reduced contraction (negative inotropic effect) resulting in cold, tinnitus, dizziness, weakness and visual disturbances. This decreased heart output, consciousness as a result of an increase symptom occurs for a few seconds before loss of consciousness, their consciousness, if they tried to sit or stand up again, there in parasympathetic tone, and reduction in blood supply to the usually when a person is sitting or standing. For patients who gain brain. At the other end of the spectrum call vasodepressor caused from several minutes to several hours may be in place [7-9]. may be unconsciousness recurrence. Nausea, sweating and pallor by low blood pressure without much change in heart rate, this phenomenon occurs during vasodilation. Most patients with Anesthesiologists with the incident, has repeatedly insertion in regional anesthesia (epidural catheter Embed vasovagal syncope, a mixed response between the two ends of the some stimuli, traumatic stress, any unpleasant or painful stimuli, encountered in the operating room. Patient anxiety and catheter whole show [3]. Prolonged standing or sitting vasovagal included performed spinal, caudal) may cause reflux [11,12]. Spinal J Anest & Inten Care Med 5(1): JAICM.MS.ID.555653 (2018) 001 Journal of Anesthesia & Intensive Care Medicine

a. Group 1: and epidural anesthesia with an incidence of bradycardia and b. Group II:The level of numbness in the area S1-S5, vasovagal reactions or asystole, and sudden loss of consciousness hypotension associated with bradycardia, but less common Classification based numbness on types of the of lower operations level of T10. rehabilitation outcome are usually good but could permanently can be seen along with them. Delays in treatment and General surgery: surgery, pilonidal sinus surgery, Fisher surgery, urological surgery: the withdrawal of ureteral stones, cause brain damage [12-15]. Risk of asystole can exist until after Cystocels Rectocele/ perineorrhaphy, orthopedic surgery: Surgery the surgery [16]. The risk of vasovagal reactions during spinal TURP, varicocelectomy. Women and gynecologic surgery: repair anesthesia is life-threatening 3/1000 persons. 5% is the incidence avoid these complications, the previous history of vasovagal and of bradycardia and hypotension in spinal anesthesia [17]. To onClassification Femur/surgery based on the on leg/ankle the time surgery of vasovagal on the legs and feet. Sitting, moving time of anesthesia, the time of spinal lidocaine its intensity is important. These side effects may occur during injection, immediately after giving Positions, during the surgery. incidence of vasovagal response during spinal anesthesia for our collection [18-20]. In this study, we intended to study the Classification based on the positioning of the patients during anesthesia after surgeryMethod in a general hospital in Khorramabad (city west of Iran).

Immediately after spinal patient was supine, for the first 3-5 This study comprises of population of patients who were under about 30 degrees above the head. study. Inclusion criteria for the study included people over 15 minutes and then sat saddle spinal patients were in positions spinal anesthesia, it was a descriptive type of epidemiological years, patient satisfaction for spinal anesthesia, sensory levels Classification based on the positioning of the patients during surgery contraindications to spinal anesthesia and enforcement action Supine, lithotomy, Prone. lower than the T10. Exclusion criteria included patient refusal, once. After the approval of the project in the Research and Ethics to partake in the research by the anesthesiologist more than After collecting the information, the data were entered Committee of the Council of Lorestan University of Medical consulting a statistician. into SPSS software and statistical analysis was performed by Results Sciences, with written consent from the patients in May, patients for elective surgery under spinal anesthesia with lower levels of containing all patient information including gender, age, BMI, undergone spinal anesthesia. In terms of gender distribution, T10 candidates were enrolled into this study. A questionnaire type of surgery, fasting time in hours, being elective or emergency During this two-month study of 284 patients who had recorded before surgery. 117(41%) were women and 167(58%) were men. The mean age surgery, and ASA class history of vasovagal reflex, was asked and of the patients was 38.27±15.1years with a minimum of 18 and maximum of 87 years. Also, the average BMI of the patients was The idea was that way after entering the operating room 26.49±9.3.267 patients were elective patients and 17 patients with the patient catheter to the vessel was 18. The patient was were operated on an emergency basis. Relationships between age, administered with Ringer’s lactate serum 15mg/kg 30-60 minutes incidence and lack of vasovagal response during spinal anesthesia invasive measurement of blood pressure and the ECG. Patients before anesthesia. We monitored patients pulse oximetry, non- were compared. Reflex in people who had an average age of received premedication and spinal anesthesia in a sitting position 29.85±8.5 and the amount of reflux in patients were 36±15.2 years. Based on the results of the independent t-test there was a with the needle number 25 of the L4-L5 or L3-L4 space with 5% significant difference in terms of average age, thus the incidence lidocaine and was carried out by only one anesthesiologist. The of vasovagal response during spinal anesthesia is significantly and blood pressure at intervals of one minute to ten minutes after Table 1: proper position for patients sitting or lying down, the heart rate higher in younger individuals. (P=0.03) (Table 1) response during spinal anesthesia. Demographic variables in 284 patients of vasovagal each block and then every 5 minutes until the end of surgery was Variables Prevalence/Mean consciousness, bradycardia and hypotension less than 50 primary recorded. In case of vasovagal syndrome with symptoms of loss of Gender Male 167 and lower blood pressure to less than 30%without area of 117 numbness above the T10 case was positive. Anesthesia level was Age (years) done with the tip of the needle using pin print evaluation method, Female at intervals of 5 minutes until the numbness was determined BMI 38.27±15.1 stable. The event frequently requires treatment in such a way Surgery 26.49±9.3 that the head position or leg is elevated; liquids and atropine Elective 271 were administered. Epinephrine was administered to a patient in Emergency 17 asystole. Measures related to spinal vasovagal time on stage was divided. Classification based on level after spinal anesthesia: How to cite this article: Sepideh V, Siavash B, Badiozaman R. The Incidence of Vasovagal Response in Spinal Anesthesia during Surgery. J Anest & 002 Inten Care Med. 2018; 5(1) : 555653. DOI: 10.19080/JAICM.2018.05.555653. Journal of Anesthesia & Intensive Care Medicine

The relationship between BMI and the occurrence of reflux levels during surgery were evaluated by spinal anesthesia. 198 during spinal anesthesia were compared. Patients who had an people were at the level of anesthesia below T10 and 5 people had average BMI of reflexes, 31.43±3.8 and mean BMI of patients the reflexes, the descriptive statistics estimate that the incidence who had reflux was, 25.94±3.37. According to independent t-test was 2.5%. Anesthesia level was 72 at S1-S5, and 9 people gave there was a significant difference between the mean BMI and vasovagal response. The incidence of vasovagal response in this incidence of reflexes, it can be concluded that the possibility of a sensory level was 12.5% according to the Chi-square test, there vasovagal response in people with higher BMI was higher during wasTable a 4significant : Effect of differenceelective or emergencybetween the surgery two levels. on the incidence and lack of vasovagal response. spinal anesthesia (P=0.001) (Table 2). The time of fasting in the absence of reflux were analyzed, the average duration of reflux Variable Prevalence in patients who had fasted was 9.14±1.9 hours and reflux in patients who did not fast for 8.98±1.38 hours, the independent Reflexes 25314 t-test showed no significant difference between the two groups after the fasting time before surgery, which had no effect on the Table 5: Effect of positioning of the patients. incidence of vasovagal response (P=0.11). The effect of gender on Variables Prevalence the incidence and lack of vasovagal response were evaluated, 2 Sleeping Position (Supine) patients were female and 12 male patients showed reflexes and 5 115 female patients and 155 male patients had a lack of reflexes. CV184 (2.7%) 179 The incidence in women and men was 1.7% and 7.1 respectively. Reflex The Chi-square test shows significant difference between gender ProneNon PositionReflex and that of means, the incidence of vasovagal reflex in men is 40 (12.5%)5 Table 2: Relationship between Body Mass Index and the occurrence of reflexsignificantly during higherspinal anesthesia.(P=0.03) (Table 3). Reflex 35 Lithotomy Positions Variables Mean Non Reflex BMI 46 (8.6%) Reflex 4 25.94±3.37 Non Reflex 42 Incidence of Reflexes 31.43±3.8 Duration of Reflex (hrs) The level of anesthesia S1-S5 caused by spinal anesthesia gave Not fasted more vasovagal response of the level of anesthesia lower than Fasted 9.14±1.9 anesthesia. (P=0.001) Data are expressed as means (±SD) 8.98±1.38 T10. As a result the reflex is more prevalent in the lower level of Table 3: Effect of gender on the incidence of vasovagal response.

Variables Prevalence The effect of positioning of the patients was evaluated during surgery. Among the 284 patients who received spinal anesthesia Showing Reflexes for surgery, 184 positions were in sleeping positions, and 5 were Male 12 reflexes and 179 were non-occurrence of reflux. 40 people were 2 in prone position, 5 cases of reflex and 35 were non-occurrence of Female Lacking Reflexes reflux. 46 patients were in lithotomy positions, 4 patients showed Male 155 reflexes, and 42 patients did not develop reflexes. According to 115 estimates of the descriptive statistics, the incidence rate showed 2.7% in supine position, 12.5% in prone position, and 8.6% in Female Incidence of Reflexes the lithotomy position respectively. This reflex was higher in the Male prone position of the Chi-square test, but, there was no significant 7.10% correlation between the position and the incidence of reflux (Table Female 1.70% 5). Patients in ASA class and the lack of impact of the vasovagal response were evaluated. From the Chi-square test, there was The effect of elective or emergency surgery on the incidence disease and higher. no significant association observed in the field, thus underlying and lack of vasovagal response were evaluated. In patients who had undergone elective surgery, patients without any reflexes had undergone surgery on an emergency basis at any vasovagal were 253 and 14 people showed reflexes. The patients who However the ASA class increases the rate of vasovagal response (P=0.01) (Table 6). Based on the number of surgical response were 17 people. In assessing the descriptive statistics, procedures performed in patients with vasovagal response, which the incidence rate in elective surgeries 5.2%, showed there was was 14 cases, 5 cases (3%) represent orthopedic surgery (broken no significant difference according to Chi-square test (P=0.59) leg and ankle),2 patients (4%) women represent (surgery to (Table 4). The custom of the vasovagal response in anesthesia repair Cystocels and Rectocele) and 7 patients (6%) were general

How to cite this article: Sepideh V, Siavash B, Badiozaman R. The Incidence of Vasovagal Response in Spinal Anesthesia during Surgery. J Anest & 003 Inten Care Med. 2018; 5(1) : 555653. DOI: 10.19080/JAICM.2018.05.555653. Journal of Anesthesia & Intensive Care Medicine

the object by subject neurocardioscopic syncope after spinal surgery (5 pilonidal sinus, 1 Fisher 1 hemorrhoidectomy), respectively. The incidence rate shows higher reflexes in general anesthesia was performed. In this study, one of the causes of surgery, but based on Fisher’s exact test between the type of syncope, the movement of blood in the lower extremities is and thus severe bradycardia or asystole and syncope occur that surgery and the incidence of vasovagal response, there was no expressed, which then activates the sympathetic nervous system patients studied, 21 had a history of vasovagal syndrome before, cause bradycardia in patients due to the above results, although significant correlations (P=0.266) (Table 6). Among the 284 among these, 9 (42%) patients had experienced during the recent we can also have multiple causes [24,25]. study. In patients with a positive history of vasovagal syndrome, injected into the epidural catheter, patient suffered a sudden In a study conducted in Japan in 2011 by Tajiri et al. [26] when that is in a recent study of 263 patients, were 5 (1.9%) people reappearance there a history of vasovagal syndrome. suffer from this syndrome (P=0.001), between the index and their Table 6: Number of surgical procedures performed in patients with loss of consciousness was associated with asystole The patient vasovagal response. is immediately injected with 0.5mg atropine sulfate and oxygen insert the catheter as one of the factors of vasovagal syncope, and return to the previous situation. The result of this study is to Surgical Procedure Prevalence the hypothesis that anxiety caused by pain can lead to vasovagal OrthopedicSurgery to RepairSurgery Cystocels (broken andleg and Rectocele ankle) 5 (3%) elevation. The result of this study is to insert a catheter as one of General Surgery vasovagal syncope and the hypothesis that anxiety caused by pain, 2 (4%) male patients undergoing inguinal hernia surgery at the time the can be caused frequently mentioned [26]. We also study a case of Pilonidal Sinus 7 (6%)5 1 spinal needle enters and the anesthetic was injection, dizziness, Emorrhoidectomy 1 Fisher low blood pressure and sweating resulted, which is different from Discussion our study, spinal anesthesia and epidural was done in the study Cardiogenic syncope (vasovagal response) is one of the of Tajiri et al. [26] but in the study of caplan et al. [27] they noted the incidence even in healthy people. This research resulted in the death of 14 cases of cardiac arrest and severe brain damage known side effects of medical interventions.Vasovagal response in patients undergoing spinal anesthesia which were reported. usually occurs when a person is exposed to certain irritation The results of the investigation of complaints due to anesthesia with symptoms such as bradycardia, hypotension, dizziness, incidence of vasovagal response during spinal anesthesia for the during the years 1978-1986 were during the surgery, most of sweating and even asystole [1,2]. In this study, we examined the which occurred after the block. At that time, cardiac arrest, heart surgery. Some researchers believe that the possibility of VVR arrest occurred in less than 2 minutes. Early signs in order of on young people is more [19,21]. In our study, the mean age of rate, and blood pressure drop was gradual. On average cardiac of consciousness. frequency included bradycardia/ hypotension/cyanosis and loss patients studied in our vasovagal syndrome were 29.85±8.5 years, the incidence of patients who had no reflux was 36±15.2 years bradycardia, and other fairy intraoperative complications showing significant differences. But young people more prone In two studies perspective valance and risk factors for to reflux have not been confirmed in all studies. For example, in the study of Professor Tiziana and Carol Cheng in America heart were evaluated during spinal anesthesia. In 2700 patients with center about neurocardioscopic syncope. From 1980 to 2004, it bradycardia were 10%, Hypotension, 22% and nausea 10%.None was observed that neurocardioscopic syncope occurs in 3% of of the patients were not experiencing asystole. The most important admitted to hospital. 15 percent of them are children under 18 patients attending emergency cases, that 6% of all cases were factor in the occurrence of these events was sensory level T5-T6, and more. Bradycardia was higher in young and ASA class1 and years, and 23% over 18 years. The incidence of syncope had a vice versa, hypotension was higher in the elders. The incidence of there is an increase in the incidence of vasovagal syncope. direct correlation with increasing age. So that as age is increased, bradycardia after a few heartbeats and sudden reversal increases with the switch that increases the venous return which is possible et al. [28] at the University of Manchester in 2009 on the number only with the express vasovagal reaction. A study by Mac Kunshan The limitation in our study was that age and patients under the age of 15 years were not evaluated, perhaps because there of patients who were candidates for ureteral stones surgery, is consistency in our results in Tiziana study, 63% of all cases of vasovagal syncope in men [22], in our study the incidence of sitting positions during spinal anesthesia, was raised as a risk occur frequently in men. The results show a higher prevalence factor and the risk of vasovagal syndrome is increased in this [23] they found that the predisposing factors in the incidence of position. Treatment of 107 people in sleeping positions and 127 in male to female ratio was 4.1. In another study by Assarian et al. prone positions and 50 were in lithotomy positions. The incidence of vasovagal response in sleeping positions 4.6%, while in the vasovagal low weight, age, male gender, which can increase the lithotomy position 8.0% and 3.9% for prone position. According risk of vasovagal reactions with the result of our study is similar to chi-square test there was no significant differences between age and male gender in the study of Normand et al in 2015 were the position and reflex this could be due to the low proportion consistent with this study and others [21]. Yamaha in a study of How to cite this article: Sepideh V, Siavash B, Badiozaman R. The Incidence of Vasovagal Response in Spinal Anesthesia during Surgery. J Anest & 004 Inten Care Med. 2018; 5(1) : 555653. DOI: 10.19080/JAICM.2018.05.555653. Journal of Anesthesia & Intensive Care Medicine

positions. of patients who were in sitting positions, lithotomy and saddle 4. 118-120.Watkins EJ, Dresner M, Calow CE (2000) Severe vasovagal attack during regional anaesthesia for caesarean section. Br J Anaesth 84(1): 5. In a study that was conducted by Dresner et al. [29] in the and have had coronary artery disease and hypertension, spinal Cyna AM, Andrew M, Emmett RS, Middleton P, Simmons SW (2006) United Kingdom, on 34 women who were cesarean candidates Techniques for preventing hypotension during spinal anaesthesia for 6. caesarean section. Cochrane database Syst Rev 4: CD002251. (1997) Sympathovagal effects of spinal anesthesia assessed by the anesthesia was used. 33 anesthesias were performed successfully Gratadour P, Viale JP, Parlow J, Sagnard P, Counioux H, et al. and only one was not feasible. In 6 cases (0.18%) mild transient 7. spontaneous cardiac baroreflex. Anesthesiology 87(6): 1359-1367. hypotension occurred and only one vasovagal syncope were (2005) [Effects of lumbar spinal nerve analgesia on the cardiovascular observed for bradycardia and loss of consciousness. The study Hanefeld C, Miebach T, Bulut D, Theodoridis T, Rubenthaler F, et al. average risk of heart disease - CVD was vasovagal syncope. 8. system]. Z Orthop Ihre Grenzgeb 143(1): 86-90. In our study, 20 patients were in class II ASA, 3 of them have Hanefeld C, Ohlgard P, Miebach T, Kleinert H, Mügge a, et al. (2006) incidence of reflexes. Out of the 3 people, 2 of them had disease [Acute cardiovascular reactions to cervical nerve root infiltration]. Z of chronic hypertension and were receiving treatment. The Chi- 9. Orthop Ihre Grenzgeb 144(1): 27-32. square test in our study shows a significant relationship between Manchikanti L, Malla Y, Wargo BW, Cash KA, Pampati V, et al. (2012) underlying disease and the incidence of vasovagal response which Laurent et al. [30] in the department of gynecologic in Spain on Complications of fluoroscopically directed facet joint nerve blocks: a was consistent with the study of Dresner. In a study in 2012 by prospective evaluation of 7,500 episodes with 43,000 nerve blocks. 10. Pain Physician 15(2): E143-E150.

4018 women who were undergoing hysteroscopy. 115 cases of medication].Tolksdorf W, MerkelAnaesthesist G, Rehder 33(7): H, Rey 307-310. ER, Berlin J (1984) [Psychological aspects of spinal anesthesia. Vasovagal syncope and anxiolytic complications that require hospitalization period more than 7.2% 11. of them were suffering from vasovagal syncope. In our study, 284 Laegeforen 126(17): 2250-2252. Schuster P (2006) [Syncope in children and young adults]. Tidsskr Nor patients were studied, 14 of them were suffering from vasovagal 12. syncope, which was 4% according to the study, as compared to studies. Predicted and lead to better management of patients after Haemodynamic effects of the position chosen for the insertion of an our study, and there was a significant difference between the two Chadwick IS, Eddleston JM, Chandelier CK, Pollard BJ (1993) the surgery. 13. epidural catheter. Int J Obstet Anesth 2(4): 197-201. Conclusion Soltani Mohammadi S, Hassani M, Marashi SM (2014) Comparing the e13969.squatting position and traditional sitting position for ease of spinal needle placement: A randomized clinical trial. Anesth Pain Med 4(2): The incidence of vasovagal response in younger people, male anesthesia--a summary. Middle East J Anesthesiol 19(6): 1291-1303. as well as people who have a higher BMI is higher. The rate of 14. Siddik Sayyid S, Zbeidy R (2008) Practice guidelines for obstetric vasovagal response in patients who have an underlying disease 15. is more. To prevent vasovagal response, measures such as proper Bilotta F, Stazi E, Zlotnik A, Gruenbaum SE, Rosa G (2014) hydration before anesthesia, patient monitoring and knowing the Neuroprotective effects of intravenous anesthetics: a new critical Acknowledgement 16. perspective. Curr Pharm Des 20(34): 5469-5475. history of previous attacks is frequently recommended. coma. N Engl J Med 363: 2638-2650. Brown EN, Lydic R, Schiff ND (2010) General anesthesia, sleep, and 17. Medical Sciences, Khoramabad, Iran house staff into anesthesiology: A longitudinal evaluation of factors Financial support was offered by Lorestan University of responsibleAugustin ID, for Long selecting TR, Rosea career SH, in Wass anesthesiology CT (2014) and Recruitment an individual of Conflict of Interest training program. J Clin Anesth 26(2): 91-105. 18.

EthicalThe authors Approval have no conflict of interest Barreveld A, Witte J, Chahal H, Durieux ME, Strichartz G (2013) Preventive analgesia by local anesthetics(): The reduction of All procedures performed in studies involving human postoperative pain by peripheral nerve blocks and intravenous drugs. 19. Anesth Analg 116(5): 1141-1161. Masamoto K, Kanno I (2012) Anesthesia and the quantitative participants were in accordance with the ethical standards of evaluation of neurovascular coupling. J Cereb Blood Flow Metab 32(7): the institutional and/or national research committee and with 20. 1233-1247. comparable ethical standards. (2013) Labor epidural anesthesia, obstetric factors and breastfeeding the 1964 Helsinki Declaration and its later amendments or Dozier AM, Howard CR, Brownell EA, Wissler RN, Glantz JC, et al. Referencces 21. cessation. Matern Child Health J 17(4): 689-698. 1. Noormand R, Shafiee A, Davoodi G, Tavakoli F, Gheini A, et al. (2015) 2. Srivathsan K, Lee RW (2003) Swallow Syncope. East 26: 2002-2003. Age and the Head-Up Tilt Test Outcome in Syncope Patients. Res basic life support in medical college. Natl J Med Res 1(2): 80-82. 22. Cardiovasc Med 4(4): e27871. Chaudhary A, Parikh H, Dave V (2011) Current scenario: Knowledge of 3. 1162.Chen LY, Shen WK (2006) Neurocardiogenic syncope: latest 18: 527-533. pharmacological therapies. Expert Opin Pharmacother 7(9): 1151- Mordecai MM, Brull SJ (2005) Spinal anesthesia. Curr Opin Anaesthesiol

How to cite this article: Sepideh V, Siavash B, Badiozaman R. The Incidence of Vasovagal Response in Spinal Anesthesia during Surgery. J Anest & 005 Inten Care Med. 2018; 5(1) : 555653. DOI: 10.19080/JAICM.2018.05.555653. Journal of Anesthesia & Intensive Care Medicine

23. 28. Mcconachie I (1991) Vasovagal asystole during spinal anaesthesia.

Assarian Z, Abed Haghighi B, Javadi I, Fotouhi A, Seighali F AN (2011) Risk factors for vasovagal reactions during blood donation. Sci J Iran 29. AnaesthesiaDresner M, 46(4):Pinder 281-282.A (2009) Anaesthesia for caesarean section in Blood Transfus Organ 7(4): 221-226.

24. mediatedIshiyama T,syncope. Shibuya J K,Anesth Terada 26(1): Y, Iwashita 103-106. H, Masamune T, et al. (2012) women with complex cardiac disease: 34 cases using the Braun Cardiac arrest after spinal anesthesia in a patient with neurally 30. SpinocathPovedano B,spinal Arjona catheter. JE, Velasco Int J ObstetE, Monserrat Anesth JA, 18(2): Lorente 131-136. J, et al. (2012) 25. Soong C, Chen BH (2015) Syncope confusion. CMAJ 187(7): 521. Complications of hysteroscopic Essure (®) sterilisation: Report on

26. Gynaecol 119(7): 795-799. 4306 procedures performed in a single centre. BJOG An Int J Obstet Tajiri O, Tateda T, Ito H, Yago Y, Kanazawa M (2009) A case of neurocardiogenic syncope with asystole during insertion of epidural 27. catheter. Japanese J Anesthesiol 58(9): 1154-1157. cardiac arrest during spinal anesthesia: A closed claims analysis of predisposingCaplan RA, Wardfactors. RJ, Anesthesiology Posner K, Cheney 68(1): 5-1. FW (1988) Unexpected

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How to cite this article: Sepideh V, Siavash B, Badiozaman R. The Incidence of Vasovagal Response in Spinal Anesthesia during Surgery. J Anest & 006 Inten Care Med. 2018; 5(1) : 555653. DOI: 10.19080/JAICM.2018.05.555653.